Pregabalin

[birchswing]

In order to start from scratch a bit, I was reading an overview of treatment options for GAD in the Psychiatric Times. I noticed how favorable pregabalin appears. I remember doing research on medications to both help with benzo withdrawal and to help with anxiety around 2005 and finding this medication and wondering why it wasn't being used for anxiety. Ten years later and I'm still not sure why. The local treatment center near me is just now starting to use gabapentin instead of phenobarbital for benzo withdrawal, which seems like a leap made from the stone age, but I wonder why pregabalin isn't more prevalent in both inpatient rehab and outpatient use. I just read that the most commonly prescribed psychiatric drug in 2009 was Xanax. How can that be when options like pregabalin exist?

Here is the info from the Psychiatric Times:

Two similarly designed randomized, placeboand active comparator–controlled, double-blind studies evaluated the efficacy of pregabalin versus lorazepam for the treatment of GAD. The pregabalin groups and the lorazepam group all experienced greater reductions in HAM-A score by week 4 compared with placebo, with no observed statistically significant differences among the active-treatment groups. Pregabalin at its highest study dose (600 mg) produced reductions in the psychic and somatic anxiety HAM-A subscale scores that were statistically superior to those produced with placebo, whereas lorazepam produced reductions that reached statistical significance versus placebo with respect to only the somatic subscale. The improvements in HAM-A score produced by the active-treatment groups were apparent by week 1 of the study.13,14

The relative efficacy and early onset of effect of pregabalin versus commonly used benzodiazepines may represent a new therapeutic intervention for GAD as both a monotherapy (after failure of an initial monotherapy) and as an augmentation strategy. Pregabalin is renally excreted and therefore poses a low risk of drug-drug interactions, lacks withdrawal or physical dependence risk, is associated with minimal adverse effects (dizziness, weight gain, insomnia), and is safe and well tolerated. A potential role for pregabalin may be in patients who are tapering off long-term benzodiazepine monotherapy for GAD. [I said this 10 years ago and was ignored!]



- See more at: http://www.psychiatrictimes.com/spe...nxiety-disorder/page/0/4#sthash.0iXYs8B7.dpuf

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[shan564]

I generally prescribe gabapentin before pregabalin because it's a similar drug and it's cheaper. Pregabalin is advantageous due to its longer half-life, so you only have to take it BID rather than TID.

Most people won't prescribe either for benzo withdrawal because it's a dangerous syndrome, so people tend to try to stick to the more well-established treatments.

 

[splik]

he never said anything about benzo withdrawal, rather tapering off benzos. I think this is fairly well established. carbamazepine, depakote, and gabapentin have all been used in facilitating tapering off benzos. i tend to prefer gabapetin. also it isn't necessary to rx TID i will often rx BID or even just qhs for benzo tapering. i also don't use pregabalin often because i can't usually as no one will pay for it.

 

[shan564]

he never said anything about benzo withdrawal, rather tapering off benzos. I think this is fairly well established. carbamazepine, depakote, and gabapentin have all been used in facilitating tapering off benzos. i tend to prefer gabapetin. also it isn't necessary to rx TID i will often rx BID or even just qhs for benzo tapering. i also don't use pregabalin often because i can't usually as no one will pay for it.

True, I meant to refer to prophylaxis of benzo withdrawal in the detox setting rather than actually treating active withdrawal - I was referring to the statements "I remember doing research on medications to both help with benzo withdrawal," "just now starting to use gabapentin instead of phenobarbital for benzo withdrawal," and "I wonder why pregabalin isn't more prevalent in both inpatient rehab" (since we'd usually use benzos in inpatient rehab for detox purposes). I prefer to use longer-acting drugs (i.e. librium) in the detox setting.

I've heard of a local treatment center using Depakote and gabapentin for detox when they had a transient problem with their controlled substances license, and it worked fine.

I've used gabapentin in the outpatient setting in lieu of benzos for people with a history of addiction, but gabapentin is still not without abuse potential. I rotated at an opiate clinic (where most patients were on suboxone) where we were prescribing gabapentin a lot for that purpose, and diversion eventually became a big problem - I guess people liked the feeling of combining a hefty dose of gabapentin with suboxone.

For patients who have anxiety and neuropathic pain, I like prescribing gabapentin if an SNRI or TCA isn't enough. I prefer it because of cost, but pregabalin does have a longer half-life - obviously you can dose it however you think is appropriate for the patient. If there's no other indication for gabapentin/pregabalin, I still try to use other drugs first (i.e. sympatholytics), but I'd choose it over a benzo. It's rare that I end up in a situation in which CBT and an antidepressant aren't enough.

Interestingly enough, while I was typing that last paragraph, an ad for Lyrica came on the TV.

 

[birchswing]

True, I meant to refer to prophylaxis of benzo withdrawal in the detox setting rather than actually treating active withdrawal - I was referring to the statements "I remember doing research on medications to both help with benzo withdrawal," "just now starting to use gabapentin instead of phenobarbital for benzo withdrawal," and "I wonder why pregabalin isn't more prevalent in both inpatient rehab" (since we'd usually use benzos in inpatient rehab for detox purposes). I prefer to use longer-acting drugs (i.e. librium) in the detox setting.

I've heard of a local treatment center using Depakote and gabapentin for detox when they had a transient problem with their controlled substances license, and it worked fine.

I've used gabapentin in the outpatient setting in lieu of benzos for people with a history of addiction, but gabapentin is still not without abuse potential. I rotated at an opiate clinic (where most patients were on suboxone) where we were prescribing gabapentin a lot for that purpose, and diversion eventually became a big problem - I guess people liked the feeling of combining a hefty dose of gabapentin with suboxone.

For patients who have anxiety and neuropathic pain, I like prescribing gabapentin if an SNRI or TCA isn't enough. I prefer it because of cost, but pregabalin does have a longer half-life - obviously you can dose it however you think is appropriate for the patient. If there's no other indication for gabapentin/pregabalin, I still try to use other drugs first (i.e. sympatholytics), but I'd choose it over a benzo. It's rare that I end up in a situation in which CBT and an antidepressant aren't enough.

Interestingly enough, while I was typing that last paragraph, an ad for Lyrica came on the TV.

I guess we should distinguish between tapering and withdrawal symptoms. You can be switched to Librium and still have withdrawal symptoms while tapering the Librium. When you say you use Librium, I assume you mean that you cross over to the Librium from a shorter acting benzo and then taper that. And I can see why you would want to avoid adding another agent. The body is already very sensitive during that process, and there are many people in the benzo community who have tried augmenting with pregabalin, gabapentin, supplements, etc., and just find that there is nothing that helps but time. Some also complain that coming off pregabalin and gabapentin carries its own symptoms. My question was more why pregabalin isn't used if something is to be used, especially since it's cited in the Psychiatric Times specifically for benzo withdrawal. But I can see what you're saying about avoiding adding one more thing that could complicate matters. People in the withdrawal state are already very sensitive quite often, and it does seem like time is the main healer. There are some studies with gabapentin though that show people can withdraw faster than without it. Faster isn't always better necessarily and carries the risk of increased kindling.

 

[shan564]

Oh, so you're suggesting adding pregabalin to cover for withdrawal symptoms caused by tapering the benzo that somebody is already taking?

 

[birchswing]

Oh, so you're suggesting adding pregabalin to cover for withdrawal symptoms caused by tapering the benzo that somebody is already taking?

Exactly. This is already done with gabapentin in some cases. Was just curious why it isn't done as much with pregabalin. Seems to be a cost issue from what I've read in the thread so far.

 

[birchswing]

yeah also why would you use pregabalin instead of gabapetin? it's a me too drug. it's not even just cost, more to the point is you usually need prior authorization to rx pregabalin. i sure as hell am not going to the pain of getting PA for pregabalin but yes you could use it instead

I haven't used either so I don't know the benefits of one or the other. On the benzo forums, Neurontin is often referred to as *****tin (as in it makes you a *****). I don't know if pregabalin has a less stupefying effect. The other consideration is that the Psychiatric Times lists pregabalin as a first-line option for GAD so it struck me as something that a person might stay on after tapering to help with the original indication for the benzos, whereas I haven't heard of gabapentin officially being used for anxiety.

 

[TexasPhysician]

Pregabalin has street value and some people become addicted to it. That plus $ are reasons you don't see it in addiction centers.

 

[Doctor Bagel]

Pregabalin has street value and some people become addicted to it. That plus $ are reasons you don't see it in addiction centers.

With money really being the big one. It doesn't have a greater addictive potential than gabapentin. Still, though, it's safer than benzodiazepines, and we have evidence suggesting that gabapentin can be helpful in the treatment of addiction.

Does pregabalin have greater street value than gabapentin?

 

[Shikima]

I haven't used either so I don't know the benefits of one or the other. On the benzo forums, Neurontin is often referred to as *****tin (as in it makes you a *****). I don't know if pregabalin has a less stupefying effect. The other consideration is that the Psychiatric Times lists pregabalin as a first-line option for GAD so it struck me as something that a person might stay on after tapering to help with the original indication for the benzos, whereas I haven't heard of gabapentin officially being used for anxiety.

I think you may be referring to Topamax.

 

[birchswing]

I think you may be referring to Topamax.

For anxiety? Pregabalin is definitely used for GAD.

 

[Doctor Bagel]

For anxiety? Pregabalin is definitely used for GAD.

Topamax is the medication most known for making you feel less sharp. It's known as Dopamax. I've never heard the phrase *****tin. Not doubting it's used because I don't hang out at those message boards, but it's new to me.

 

[birchswing]

Topamax is the medication most known for making you feel less sharp. It's known as Dopamax. I've never heard the phrase *****tin. Not doubting it's used because I don't hang out at those message boards, but it's new to me.

Ahh, gotcha. Yes, they use the term *****tin. Apparently that's the effect it has, but a lot of people in benzo withdrawal already have the hard-to-define brain fog. But if you Google *****tin I see people talking about forgetfulness on various non-benzo forums, as well. Not sure if pregabalin is better in that regard or not. Relatively few people on the benzo boards have used it.

Dopamax is new to me.

 

[Doctor Bagel]

Ahh, gotcha. Yes, they use the term *****tin. Apparently that's the effect it has, but a lot of people in benzo withdrawal already have the hard-to-define brain fog. But if you Google *****tin I see people talking about forgetfulness on various non-benzo forums, as well. Not sure if pregabalin is better in that regard or not. Relatively few people on the benzo boards have used it.

Dopamax is new to me.

I would doubt pregabalin is much better than gabapentin for this. As mentioned by other posters, I doubt it's much better than gabapentin in any significant way. It's just more expensive.

 

[splik]

pregabalin = $$$$gabapentin

 

[Doctor Bagel]

Ahh, gotcha. Yes, they use the term *****tin. Apparently that's the effect it has, but a lot of people in benzo withdrawal already have the hard-to-define brain fog. But if you Google *****tin I see people talking about forgetfulness on various non-benzo forums, as well. Not sure if pregabalin is better in that regard or not. Relatively few people on the benzo boards have used it.

Dopamax is new to me.

So I'm going to ask here -- does anything really good come from message boards where side effects for medications are discussed ad nauseum? We know in psychiatry that the more side effects you mention, the more side effects your patient (especially a somaticizing, anxious patient) will experience. I'm an obsessive person, too, who reads way too much online about things in my life, and it's generally not that helpful.

 

[PistolPete]

With money really being the big one. It doesn't have a greater addictive potential than gabapentin. Still, though, it's safer than benzodiazepines, and we have evidence suggesting that gabapentin can be helpful in the treatment of addiction.

Does pregabalin have greater street value than gabapentin?

Really? I've always thought that pregabalin was much more highly addicting than gabapentin.

 

[birchswing]

So I'm going to ask here -- does anything really good come from message boards where side effects for medications are discussed ad nauseum? We know in psychiatry that the more side effects you mention, the more side effects your patient (especially a somaticizing, anxious patient) will experience. I'm an obsessive person, too, who reads way too much online about things in my life, and it's generally not that helpful.

Well, in being honest about myself I worry I'll paint a picture that throws many other people with better experiences under the bus. My progress has been slow, and I don't think it's representative of the majority of people on those boards, many of whom are completely off the benzos.

I would credit the online community with alerting me to the harms of benzodiazepines. What was problematic for me is that once I learned about the harms I became terrified of withdrawal. I read about the possibility of seizures. So, even while logically knowing seizures don't typically happen during a taper, my mind goes there. For many years reading about benzos online was like wanting to look at the sun but knowing I couldn't. I literally got extremely anxious just from trying to get informaiton. I would look and then have to look away. The online information both motivated me to get off benzos but also made me terrified of it.

I have to credit online information, though, with both learning about the harms and learning about the safe ways to withdraw versus unsafe ways. There was, for me, a vacuum in which I had not gotten any of this information from the doctors who were prescribing me these medications. I have never had a doctor encourage me to withdraw nor have I had one tell me that it would be dangerous if I suddenly stopped taking the medicine. So I would say the online information has stood in for a lack of normal medical care. I think that's why I cling to it.

I talked yesterday with my therapist about the idea of in patient detoxing. The problem that led to that conversation is that my psychiatrist currently, while she is more knowledgable about benzodiazepines, is only the best of a lot of bad options out of available psycchiatrists. She plays voicemails to herself, reads and sends text messages, and on and on, while I am talking. She's just not present. She'll encourage me to taper, but she doesn't do phone calls or e-mails between appointments and I only see her every two months, and when I see her, she's really not there. I need a lot more reassurance. With my cardiologist, any time I've emailed him, I hear back within a day. My psychiatrist just isn't available--not even for emergencies. I asked my psychologist again if I was crazy for thinking there were no good psychiatrists around here and he laughed and said absolutely not. My two psychiatrists prior to this one have lost their medical licenses for malpractice. The only psychiatrist that my psychologist thinks is decent only sees you for the first appointment and after that you see a nurse practitioner. So I'm considering going inpatient. Not sure if I will. It's very scary. But also scary not to improve, as well. I don't entirely trust the inpatient clinics either as they don't seem to want to disclose what they do. I found one that uses gabapentin. There is one near me that uses flumazenil which sounds insane. (http://www.thecolemaninstitute.com/benzo-detox)


EDIT:
Maybe flumazenil isn't so crazy:
http://www.ncbi.nlm.nih.gov/pubmed/23126253

 

[shan564]

I don't think I've ever prescribed pregabalin over gabapentin, but I might start doing it when it gets cheaper. I know there's no data for this with gabapentin/pregabalin specifically, but I just prefer prescribing longer-acting drugs when addiction potential is a factor.

 

[dozitgetchahi]

I would doubt pregabalin is much better than gabapentin for this. As mentioned by other posters, I doubt it's much better than gabapentin in any significant way. It's just more expensive.

I have a small (but vocal) cabal of patients who insist gabapentin did nothing for their neuropathy but pregabalin did.

I've also heard neurologists say that while gabapentin is only marginally effective for seizure control (and thus borders on useless), pregabalin actually works well and is thus very useful.

 

[shan564]

I have a small (but vocal) cabal of patients who insist gabapentin did nothing for their neuropathy but pregabalin did.

I've also heard neurologists say that while gabapentin is only marginally effective for seizure control (and thus borders on useless), pregabalin actually works well and is thus very useful.

Were they on equivalent doses of gabapentin? Pregabalin is easier to dose.

 

[Doctor Bagel]

Really? I've always thought that pregabalin was much more highly addicting than gabapentin.

It's probably not. I think it's just there are more studies showing addictive potential on it. There's really no logical reason why it would be more addictive.

 

[Ceke2002]

So I'm going to ask here -- does anything really good come from message boards where side effects for medications are discussed ad nauseum? We know in psychiatry that the more side effects you mention, the more side effects your patient (especially a somaticizing, anxious patient) will experience. I'm an obsessive person, too, who reads way too much online about things in my life, and it's generally not that helpful.

Similar to Birchswing's experience I did find specific medication forums to be useful to a certain degree, namely reassuring me that I wasn't going to have another seizure during the benzo taper I was on at the time. However I did find myself having to take a large step back after a certain point, because reading and talking about side effects ad infinitum in the end just had me jumping at shadows over every real or perceived bodily twitch or ache. That's when I made the conscious decision to just trust my Psychiatrist and GP at the time, and defer any concerns to them.

I do still very occasionally utilise medication based discussion forums, although I don't participate myself. If anyone's going to end up with the one in a thousand, 'wow, that's the first time we've ever seen that' type reaction to a new medication, it'll probably be me <slight hyperbole to make a point>. I just find it helpful to find out that other people on the same medication might have had similar experiences so I can arm myself with knowledge that I can then take to my Psychiatrist/GP/whoever else so together we can make an informed decision on whether I stay on the medication, adjust the dosage, or just give it time. For example my first clinically monitored dosage of Mirtazapine was 7.5 mgs (it was actually supposed to be half that again, but butterfingers here couldn't cut the tablet in quarters properly) and it ended up almost knocking me out to the point that my Psychiatrist had to insist several times that I open my eyes and look directly at him so he could make sure I was okay. I spent the next week lying in bed or stumbling around in a complete stupor, but at some point managed to get my you know what together just enough to look up some patient experiences on medication discussion forums and very quickly found out that others had experienced similar reactions at the same dosage and it had eventually passed. I felt relieved, stumbled back into bed, gave it another week or so and apart from just having to be careful about standing up too fast I was fine after that. So yeah, I think the message boards do have their uses, but I also think the trick is not to become too enmeshed with or reliant upon them. Just my opinion of course.